at home= less stress= less falsely elevated bc stress (remember cortisol inc glucose and dec insulin). owners can monitor for attitude of animal, appetite, water and food intake, bwt, urine glucose or ketones (not sensitive but can monitor trends and changes- might help get them to your clinic REMEMBER NEVER CHANGE ANYTHING BASED ON URINE GLUCOSE- MUST DO BG CuRVE).

best at home monitor you can give-- and what you must tell owners NOT to do?

glucometers are best option but MUST NOT ALLOW OWNERS TO ADJUST THERAPY. (YOU make the changes based on the curves and clinical signs)

only do if necessary. ensure good glycemic control! no food in the AM for sx, so only 1/2 dose insulin AND MAKE SURE THEY ARE FIRST PROCEDURE!! as soon as they are under, start monitoring glucose. give 5% dextrose in the fluids. Can use regular insulin until awake enough to eat then back to SQ. Sxs prolyl happening are spay or cataracts (caused by DM in dogs, can only get rid of with sx)

If you have a diabetic animal with a prob, first thing you should do...

do a bg curve!! then eval for concurrent dzs

explain how to do a BG curve

Feed them normally, then admin insulin normally. Then check the BG every 2 or 3 hours for 12-24 hours. (if they are on Q12hr dosing, 12hr usually will suffice, do for 24 if not sure)...if BG is <125, then do Q1 hr measurements (dont want them to get too low!!) If they are showing CSs at night, do the BG curve over night. If once a day insulin, do 24hr BG curve.

what is low point of BG curve called? highest point?

ACME= highest point. Nadir= lowest point

adjust insulin DOSE based on..

nadir.

adjust insulin FREQUENCY based on...

acme

what should the BG nadir be like for dogs? cats? what should the pre-insulin low limit be?

DOGS: 120-300. CATS: 70-180. PRE-INSULIN LOW LIMIT: 180!!!! (

what do you think of this BG curve of a dog on Q24hr insulin?

this is an ideal BG curve for 24hr dosing. the nadir is in the normal range basically (normal rang for dog is 120-300, cat is 70-180), this is just over 100, and most of the day their BG is staying within the normal range of <200

what should the acme be?

remember this is the normal range the glucose should max out to ideally, although as long as they aren't ketotic it should be ok. Dogs should be around 200 or lower, cats should be around 300 or lower (keep in mind stress)

what do you think of this BG curve of a dog on Q24hr insulin?

This is NOT idea. The nadir might be in normal range at about 120 (normal range for a dog is 120-300), but the acme is like 400 and shouldnt really be going past 200 that much. Since nadir is normal, dont adjust dose. Instead, you must adjust frequency bc acme is the problem-- go from Q24hr to Q12. AND keep in mind the length of time-- most of the day he is spent too high up on the chart. This dog obv has rapid insulin metabolism.

what do you think of this BG curve of a dog on Q24hr insulin?

THiS IS INSULIN RESISTANCE-- giving the insulin didnt change the BG levels much at all. since the nadir is too high, this dog needs MORE insulin. Remember to adjust insulin dose by 10-15% at a time.

*what is insulin resistance? ***why might it happen?

insulin resistance is if theyre getting more than 2 units per kg (and normal is a quarter to a half of a unit per kg) and they are still showing CSs, it is def insulin resistance. With this much insulin they should be well regulated-- so why aren't they? EITHER: (1) INCORRECT INSULIN HANDLING/ADMIN or (2) CONCURRENT DZ (could be drugs too, like ear meds have steroids in them which are anti-insulin)

If the body has periods of hypoglycemia, you will see a rebound HYPERglycemia-- owners will notice a return of CSs: glucosuria, spot BG measurements will show up hyperglycemic-- this is why you MUST DO A CURVE IF PT IS UNREGULATED. (this is why we adjust dose based on nadir not acme)

what is going on here?

This is somoyagi effect-- note that the nadir IS SUPER SUPER LOW so then it rebounds up like crazy. acme is deceptive, but nadir will show you need to actually dec dose

Insulinoma (OPPOSITE OF DM)

weak but with good appetite (they want to eat!), seizures (low glucose and elevate epi)

what will chem look like with insulinoma?

Fasting hypoglycemia, SEVERELY LOW glucose which is repeatable

you can't just look at blood glucose to know it's insulinoma.. what else must you look at?

Insulin levels must be measured concurrently with a BG of <40 mg/dL (so HIGH insulin in face of LOW BG-- and if you draw and BG is low, you need to draw and measure BG and concurrently look at insulin- needs to be from same blood sample)

are there ketones with insulinoma?

NO. because formation of ketones is inhibited by insulin!!

how do you image an insulinoma?

(1) Radiographs: Ensure thoracic views to evaluate for metastasis (2) Abdominal Ultrasound: Usually very small and not visible-- Metastasis to liver should be evaluated. (can even do a transesophageal US to try to see the panc mass)

R/Os for hypoglycemia

(poster child: tiny puppies with not a lot of fat or mass). Cancer cachexia, sepsis, liver dz, insulinoma, hepatoma (remember liver makes insulin like growth factor one which works like insulin, makes BG low), drugs, puppies (esp small breeds- like the poster child), preg with malnutrition

sx tx of insulinoma?

excision/debulking (if you find a bump, take that. if not, debulk by taking like half the panc and hope it is in that half often too small to find) liver bx (check for metastasis), post sx risks include: pancreatitis (you poked the pancreas), DM, Cerebral laminar necrosis???? (

medical tx of insulinoma?

prednisone, Diazoxide, Streptozotocin ((she said: pred+many small meals is a good option for bad sx candidates)

prog of insulinoma?

guarded to poor, Often have metastasized at the time of diagnosis. Treatment is usually palliative

Gastrinoma

Question

Answer

what is a gastrinoma?

A gastrinoma is a tumor (G cells) in the pancreas or duodenum that secretes excess of gastrin leading to ulceration in the duodenum, stomach and the small intestine. There is hypersecretion of the HCl acid into the duodenum, which causes the ulcers.

what is Zollinger-Ellison Syndrome?

just aka for gastrinoma

who tends to get gastrinomas?

older dogs.

what are the 3 routes stomach acid is

(1) histamine (2) ACh (3) gastrin (Ach turns on the enterochromaffin cell from a nerve, so does gastrin but by hormone route, and the E cell releases histamine to turn on the parietal cell which secretes the acid)